Month: May 2016

What are you doing to make your company better? If you are employed, then it is your company. Take stock in your employer. If you can make your company more efficient, then you deserve a raise. None of us should be getting raises for time served. It is not prison, at least it shouldn’t seem like prison. Find your passion and follow it. If you don’t have passion for at least one part of your job, then reassess your career path. Once you find IT, then make yourself valuable.

“Process changes entails ‘looking for changes we can make within our system to become more efficient’”

If we believe that no system is perfect, and we can look at our own system (regardless of the profession or business) to ask ourselves ‘How can we be better’, then this will open Pandora’s box. For instance, I recently asked myself what can we as a department be doing better. There were a lot of suggestions that were thrown out. We delved into one suggestion and it a brick wall when we broached a certain subject. Pushing further, it turns out that another department limits our department. Our conversation didn’t go any further than this, but I would love to be in an upper level position to be able to bring the two departments together in order to demonstrate to the two departments how closely entwined they are with each other. This was just one suggestion of improvement that I discussed with my supervisor. In my opinion though, things will never change if they are never analyzed.

“’In the end, whether it’s a clinical process or an operational one, anything you do that is part of that process must create value for your customer’”

Who is our “customer” in healthcare? The easy answer is the patient, but that answer is too easy and cookie cutter. I would challenge that answer. That is one of our customers, but maybe not THE customer. When we look in terms of retail, who is the customer? Is it everyone that is in the store…in an ideal setting, the answer is yes, but realistically our customer is the one that is spending money on our wares. In PT, the wares are PT. The customer (the one giving us the money) though is not the patient as much as it is the insurance company. How do we best create value for our payers? We fix our patients, which some believe to be our customers. This is not to demean the patient by any means, but we have to understand who feeds us. If the patient’s had to pay our of pocket, then I would say that the patient is the customer and that would create a different set of values.

“Michael Porter, PhD, in The New England Journal of Medicine…defines value ‘as the health outcomes achieved per dollar spent.’…’Value should always be defined around the customer, and in a well-functioning health care system, the creation of value for patients should determine the rewards for all other actors in the system…value in health care is measured by the outcomes achieved, not the volume of services delivered…”

What this is saying is that the health care providers (therapists in this specific example) should get paid for doing a good job (meaning the patient gets better and avoids other costly procedures such as MRI’s, surgery, prolonged loss of work, etc) instead of getting paid for DOING a lot of stuff to the patient. In my opinion, this means that if you have back pain, then the therapist should get paid a certain amount for a specific outcome. If this outcome occurs in a short period of time, then the therapist makes more money per visit overall. There is value though in identifying patients that will not benefit from therapy and the therapist should also be rewarded for getting this patient to the proper practitioner to fix the problem. Another way to say this is that the therapist should be “punished” by having to refund money to the payer if the patient needs to undergo a surgery that the therapist though was avoidable. If we save the health care system a lot of money by avoiding surgery, then we should see a percentage of that health care savings. On the flip side, if we stated that the patient would do well with therapy and the patient did not do well, or needed surgery, then the money that we were paid should have to be paid back in order to help pay for the surgery. This is opening up a box, but as I stated before, the cream will rise to the top and those that are good at their job will learn how to maximize income by becoming better at fixing those that can be fixed and referring those that can’t be fixed on to someone else that can fix the patient.

“Companies are seeking ways to reduce costs in response to health care reforms and in anticipation of the ever-closer move away from fee for service and toward value-based care”

This is all fine and dandy, but the companies need to inform the employees what is happening in the health care world. There are many companies, mine included, that have cut jobs, which has created a more stressful environment company-wide. We all hear, do more with less, but what should be said is that “we are getting paid less and have to get creative in order to continue to stay solvent”.

“…the patient is the customer. Value, therefore, depends on patient experience…outcomes are greatly influenced by the amount of time the patient spends with actual caregivers”

My company does some things right and some things wrong. We need to assess the patient experience. This starts well before the patient is actually sitting in front of us for an evaluation. When the patient pulls into your business, is the entrance marked appropriately? Are you easy to find? Did your receptionist ensure that the patient had directions to get to your clinic? Now that the patient has found it, how easy is it to park? Does the patient have to walk a long way in order to see the clinician? Is the waiting room busy? Is the waiting room cluttered? Is the waiting room clean? Is there coffee? Is there demographic based reading material in the waiting room? Is the front desk staff warm and receptive? Does the front desk staff make an effort to remember patient names? When the patient registers for the first visit, are they simply handed paperwork to fill out, or does the receptionist offer to help? After registered, does the therapist come to the patient, or is the patient brought back to wait for the clinician? Is it a long walk to get to the clinic? Are there private rooms (or at least a private area) available to talk candidly with the patient, without the patient feeling stifled due to outsiders? Are the beds clean? Is the room inviting to the patient? Does the clinician have all the tools needed to take care of the patient?

This only describes the first 5 minutes of a patient experience and it can go on and on? Are companies still thinking about the patient experience, or simply the $$$.

I can say that my company does not ask me to violate any ethical considerations and as long as the patient is in the clinic, I am with the patient and caring for the patient. That patient is vulnerable, that’s why they are there, and I do my best to ensure that the patient understands that they are in a caring environment. This doesn’t always mean that I can help or “fix” the patient, but the patient understands that they will learn, be cared for, and get their money’s worth in the session.

“The goal is to minimize the amount of time any patient must wait to be seen once he or she has called to make an appointment…3 days or less”

I have seen wait lists of up to 2 weeks to see the practitioner of choice. This is absurd. If the patient has to wait, the therapist better be fantabulous. This is uncalled for to have a wait list longer than 3 days. My first job, we prided ourselves in getting the patient in the clinic within 24 hours if the patient wanted to be seen. It meant sacrifice at times, but the patient was always my priority.

“…examining the department’s intake procedure, its insurance verification process, and even the performance of individual PT’s who might become more efficient by changing some of their protocols”

All businesses, healthcare is not an exception, could stand to become better. There are many avenues in which to improve, as I listed many instances, which could be evaluated in the first 5 minutes of a patient experience. Could the therapist be better? Of course! Is the therapist doing something to become better…highly unlikely…unfortunately. (This is simply my observation over the course of 8 years in practice. Once we start getting paychecks and life happens, the professionalism and giddiness that we entered the profession with starts to get pushed down by other priorities)

“Lean…all about continuous improvement-taking every functional area of your practice, business, department, or organization and continuously challenging everyone who is part of it to do things better.”

This can be scary. Imagine having someone telling you that “you suck”. Scary right?! It will never happen, but unfortunately, it’s what we hear when we are told that we have to change. We can all be challenged, but how we are challenged is what matters.

Story time: Sam’s club 8298 Joliet IL. The year was about 2002 and a new GM came to the store. David was a good leader. I was working in Tires at the time and there were about 4 of us in the department on this day. He asked me to do one job and report back to him when I was done. No one else was asked to do anything more, so I was the only one working while everyone else waited for the next customer. After the first job, he gave me another…and another…and another. Six hours later, I was frustrated and angry because I was the only one working. I confronted him about it after 6 hours and he said something along the lines of wanting to see how much he could push me before I pushed back. He was surprised that it took 6 hours, as he though it would take much less. I respected him more for that, only because he told me his end-game.

“It (Lean) allows you to find the steps that are not providing value so you can eliminate them.”

Change is hard. It is hard to change what has always been done, but if no one looks at “what has always been done”, then we will never know if it can be done better, or needs to be done at all.

“incremental changes are made to a process and either accepted or rejected depending on the results”

This is similar to what we do in an evidenced based version of healthcare. We attempt to change one variable and note the result. If the result was bad, then we change back to what we were doing originally and attempt to change a different variable in order to make the patient better. This is the same concept, just applying to business instead of patient care. The trick is to allow the variable some time in order to allow itself to show its change. For instance, if I were to offer valet parking, I couldn’t assess it in one day. It may take time for my patients to realize that this is offered and even longer still for it to become an everyday occurrence. When it is established, I can then take inventory on whether it is good/bad/indifferent and if the valet needs to be improved or eliminated.

“You’re continuously making changes, but they’re easy to reverse…if you do something that doesn’t lead to significant improvements, you go back to what you were doing before.”

This is very self explanatory, but I rarely see it put into practice. Complacency is the killer of excellence. Unless we are constantly striving to improve, then we will be passed up by those that are.

“if you want to come in and start your therapy today, you can, and you can make your appointments for whenever is most convenient for you. You just have to be willing to see different therapists”

This is a very simple concept, but if the patient is never made aware that they will be seeing different therapists, then the patient may not be as happy with the convenient time as they would with the same PT. This is something that my current company has tossed around, but has not taken 100% initiative with.

“I would encourage any PT to see the journey in their setting from a patient’s perspective”

What would my patient’s think about their experience? I believe that the clinical aspect is covered thoroughly, but is there something else that I could be doing to enhance the experience?

“Patient’s were starting late because it was taking too long to do all the paperwork. In that case, she says, ‘We brought everyone together to look at all the ways we had patients register. We then figured out what was absolutely necessary-as opposed to what we were doing just because we’d always done it that way…managed to reduce the average intake time by almost 10 minutes”

This is huge for me. I hate that I have to wait for a patient to complete all of the paperwork on the initial evaluation. When I have to wait for the patient, I am left with 2 options: cut the session short so that my next patient doesn’t have to wait, or make the next patient wait. Who is more important at this stage? It would be ideal for the patient to be completely registered prior to coming in for the first appointment. Why can’t this be done when the patient comes in to schedule?

“’…quiet the external noise’ that too often exists in workplace environments…When we reduce that volume of noise, we free up our clinicians and frontline workers.”

This is interesting because this exact line was used in a previous e-mail from an employer. Unfortunately, just saying it doesn’t do much if the “leadership” doesn’t follow the same line. Noise could be anything from rumors, complaints, internal bullying, and anything that makes the frontline dissatisfied.

We all like to think of ourselves as important. “No one can do my job as good as I can.” We all think like this, or at least I hope we do.

“One successful strategy for reducing the backlog of patients, developed in the United Kingdom, is for physiotherapists to screen patients referred by GPs before a first consultation with an orthopaedic surgeon.”

I wouldn’t have thought that this was possible in the US when I first entered the profession of PT, but now I at least think that it is plausible. There are many hurdles to overcome, and the first is money. If a surgeon is not seeing a patient, then the surgeon is not making money. The ideal of this scenario is to have surgical candidates see the surgeon and for non-surgical candidates to see non-surgeons.

On the flip side, therapists will have to become owners of the profession. I have worked with many PT’s that really enjoy the “paint by number” system, otherwise known as protocols, but protocols don’t necessarily fit in an environment like the one described. We have to be able to think independently and assess patients either using pattern recognition or using something like the Hypothesis Oriented Algorithm for Clinicians.

“gatekeeper role for physiotherapists is supported by the growing body of evidence that it is effective, and that physiotherapy is an appropriate treatment for many musculoskeletal conditions”

As much as I agree with the statement that PT is effective, I don’t know if this statement supports the use for PT’s as a gatekeeper. I envision the role of gatekeeper as more of an assessor instead of a “treater”.

In the case of back pain, there are assessments that can be used prior to treating the patient in order to determine how much “help” the patient will need. When assessing the patient, there are odds ratios to determine a patient’s need for surgical intervention compared to conservative interventions.

These are the themes that a therapist must know in this type of setting.

“In the UK, the initiative has resulted in reduced and more appropriate referral to orthopaedic surgeons, more timely interventions for those unlikely to benefit from surgery, and a shorter waiting time for appropriate care for all patients.”

This is very important. Just imagine that you need a back surgery for something very serious, such as an infection or cauda equina (just know that it is serious), but you have to wait in line to see the doctor because someone has a “pulled muscle” (not very serious). If those that are definite surgical candidates can get to see the surgeon faster, this would reduce the need for the surgeon to screen the patient in order to determine the next step.

In other words, if you have back pain, it is classifiable in about 80% of cases. Roughly 70-80% of those cases could be treated appropriately with PT initially. This would prevent about 56-64% of patients needing to see the orthopaedic in order to initiate treatment.

“receives an average of 150 new referral each month to the orthopaedic outpatient department. Three orthopaedic surgeons and a registrar are available to screen 10 new and 18 review patients each week in one 3-hour clinic session…the waiting list for non-urgent care patients…waiting time of 164 weeks until their first appointment”

AND WE THOUGHT WE HAD TO WAIT A LONG TIME TO SEE THE DOCTOR! Think about this. If you had to wait over 3 years to see the doctor, would you rather wait that long or see a PT in a much shorter time? We are not at that point yet in our country, but it is coming. You will notice that you are seeing less of your MD and more of your PA’s and APN’s. There are not enough physicians to take care of all of the patients that want to see the doctor. The net question is would your rather see an expert or non-expert for your problem. There was a study, that I will go back and find to write about at a later date, that shows in terms of minimal competency, only orthopedic surgeons and PT’s pass a basic test for musculoskeletal conditions. Again, why would you want to see any one other than these two professionals for a musculoskeletal problem?

“Conditions considered for inclusion were musculoskeletal-related knee, shoulder or back pain (with or without leg pain)…excluded if their subjective history suggested any sinister disorder requiring urgent medical attention, or if they had psychosocial issues that contribute to symptom chronicity”

This study essentially compared a PT’s ability to assess patients to that of an orthopedic surgeon. I don’t know how much I agree with this because we are calling the orthopedic surgeon’s assessment the gold standard, but for lack of a better tool…it will have to do. To be fair, it was the only profession that scored higher than PT’s in terms of musculoskeletal competency.

“The physiotherapy screening appointment involved a comprehensive assessment, a provisional diagnosis and the development of a management plan in consultation with the patient…reported to the patient’s GP by letter in the same week, and a copy of the letter was filed in the patient’s medical record.”

This is where the rubber meets the road. The PT’s had to assess the patient nd diagnose the patient. Good luck with that in the states. Until we have a greater influx of DPT’s the idea of diagnosing is more like a dream. We have been pre-programmed that the physicians (MD’s, DO’s) diagnose and we give a “physical therapy diagnosis”. WTF! We have the knowledge, but not the cajones! Instead, we tell you what the problem is, but won’t tell you for fear of stepping on toes.

Because our profession is not a direct access profession, such as chiropractic care, we depend on physicians’ referrals to physical therapy. If we upset the physicians, we may see those referrals decrease in overall number.

“ Principal outcome measures of the preliminary study were:

-proportion of new referrals not needing to see a surgeon;

-the level of agreement between the physiotherapists and the orthpaedic surgeon on diagnoses and management decisions, and

-the patients’, GP’s and surgeon’s level of satisfaction with the physiotherapist-led screening initiative”

In my opinion, this is also listed in terms of order of importance. If we can cut down on the number of referrals not needing to see the surgeon, then we will effectively make the health care experience more efficient. This is the new buzzword in healthcare.

If we can agree with the surgeon’s diagnosis, that is good, but we are making the assumption that the surgeon is correct.

Finally, is the satisfaction of all involved in the study. This may be biased, as a doctor may not be satisfied with another professional taking point on a medical case.

“The orthopaedic surgeon agreed with 74% of the management decisions made by the physiotherapists…differences only in differentiating back pain of mechanical or nerve root origin, and knee pain of cartilage or articular origin.”

This is good, but not great. This only states that we both agree with each other. The good thing is that there is not much of a difference between seeing the therapist or the surgeon in regards to the diagnosis.

“experienced, well qualified physiotherapists can competently and safely undertake screening of patients referred to public hospital orthopaedic outpatient clinics with non-urgent musculoskeletal pain”

This bodes well for our profession and health care in general, especially the financial aspect of health care costs. Unfortunately, giving PT’s full, unrestricted access to patients is not on the horizon in the US.

“In the current climate of health care workforce shortages, there is a growing interest in allied health professionals undertaking additional tasks in extended roles. Two-thirds of the patients screened in this trial did not need to see a surgeon at the time of referral, but required non-surgical care, predominantly physiotherapy and exercise.”

With the shortages of MD’s, there is an increased need for other professionals to fill that gap. Physical therapy is one profession that can manage the orthopedic aspects of the MD shortage.

This is the “From the President” portion of the private practice journal. I have been contemplating my next step since finishing the DPT. There are many avenues that I would like to enter. I have the skill set in orthopedics and the background knowledge in order to successfully treat this type of condition. I still need to expand my skills regarding vestibular dysfunctions, but at that point I feel that I would have the requisite skills to start or successfully manage a private practice. I am not as interested any more in “just treating patients”. I don’t mean to sound demeaning in this aspect, but as PT, I can affect only one person at a time. As a clinical instructor, I have to ability to affect the future of our profession in terms of their mindset leaving “the program”. As a manager, or better yet a private practice owner, I would have the potential to inspire any or all of the PTs that I am managing. I spoke with Annie O’connor many years ago. (As an aside, you can either support Annie by purchasing her book: A world of hurt, or learn more about her in the interview on the “Mechanical Care Forum”). During my conversation with her, I learned how she helped to build the Rehabilitation Institute of Chicago into the powerhouse that it is today. It wasn’t always this way; through perseverance and difficult decisions the hospital became the #1 rehab hospital in America. That is the type of impact that I want to have on the profession and the patients that we serve.

“Every practice owner knows that the people with whom they surround themselves play heavily into the practices success or failures.”

Again, it has been said that you are an average of the 5 people that you spend your time with. “Spending time”…think about that. When you buy something, you get something in return. You are exchanging your time in return for something…be that time with a loved one, the latest episode of your favorite t.v. show, a new book or hanging around your friends. What are you getting in exchange? Is this making the “boat go faster” (see the episode of Spartan Up in order to understand this reference)?

If we spend our time around people that are of the same level or on a lower rung, professionally, then we have to understand that this will not elevate us professionally. Not that there is anything wrong with spending time with people that don’t elevate us, but don’t watch the “up and comers” such as Kelly Starrett, Quinn Henoch, etc and think “I could do that if I had…”. For a long time, I was satisfied with learning little by little and only affecting the patient or student in front of me…not anymore.

“We are good at getting them on board, then spending time and money training and molding them into productive team members”

If you work for a company like this…you are either lucky or sought out the opportunity.

If you are a PT, how are you being molded? Are you being molded to give the best patient experience or to charging the most units of treatment? Do you, the “Doctor”, or the aide, at best a graduate without a license, treat the patient best?

“As private practice owners, we must strive to engage all employees to feel as if they have ownership in the practice”

This goes well beyond the “private practice” realm. I currently work in a suburban hospital. I have a stage in the hospital. If we don’t make money, we won’t have jobs. If I do what is best for the hospital, without sacrificing what is best for my patients, then we will continue to prosper. These two don’t have to be exclusive of each other. When I do what is best for my patients, that in turn can translate to what is best for the hospital. For instance, many years ago I treated a patient that was so satisfied with her treatment that she transferred her medical care from the hospital that she was previously go to for tests and surgical interventions to the hospital that I was employed. Doing right by the patient turned into increased revenue for the hospital. This is how I take ownership of the “practice” (meaning the hospital). If anyone wears the hospital logo, they are part owner and have to treat their career/job as such.

“Employees need to be heard and recognized”

This is the flip side to the above point. For example, employees have to be charged to act as owners. Owners have to be charged to treat them as such. If we continue to treat employees simply as employees, then they will always act as such. I don’t want an employee. A la Dave Ramsey: “an employee shows up late, leaves early and steals while at work”. Don’t think of steal in the literal sense, but the figurative sense, as in stealing time. Owners will show up to work early, stay late and figure out how to make the business better while there.

“Empower your employees to do their best. This requires having measureable objectives for each employee and providing steady feedback to them.”

This is huge. Many times we look at “employees” and think that they don’t measure up to our ideal employee. Do we all know what an ideal employee looks like? If not, then that is a problem. How can we gauge a person’s effectiveness at their job if they don’t have a benchmark in which to hit. For instance, my current company recently rolled out a new pay structure. The problem with this is that none of us know how we are being gauged. This is a huge problem. We all think that we are doing a “job well done” and until we are told otherwise I still think I am a rockstar. That’s a problem, because I may be a total screw-up, but until I know what my measurement tool is…I am still a rockstar.

“Set yourself apart from the competition. People want to work for a winner.”

If the boss isn’t a rockstar, then the boss sets the pace of the company. The boss is always leading and people are always following. If things are not going in the right direction, then leadership will have to reflect in order to determine if they are leading in the wrong direction. The leader is such because the leader will always lead from the front, even when they try to lead from the back. For instance, no one likes a back seat driver, but at the same time we will always do what you do instead of what you say.

My dad is my superman. He is a Vietnam veteran, catcher of thieves, beater of gang bangers and overall super hero. Growing up, we lived on the wrong side of the tracks. Every area has the same tracks it seems like. Some of us grew up on the good side and were always told not to go to the other side of the tracks or viaduct or river or other such landmark. We lived near a prison, and living in Joliet you are almost always near a prison. I can remember my dad picking up a hitchhiker once and almost immediately he said do as I say, not as I do. His actions more so than his words have left a mark.

The boss has to have the same expectations placed upon him/her as he/she places on the employees. “I want to trust my employer, at times, there is enough of a lack of transparency that it is hard to trust the employer.” We’ve all either said this or though this or knew someone who did. This is an issue. The company has to treat the employees as owners, but in the same respect the employees have to deserve the treatment.

Excerpts taken from:

Brown TC. From the President. Impact: Private Practice Section of the American Physical Therapy Association. 2016;May:5.

I recently became a member of the private practice section of the APTA. I have illusions of grandeur, which include working up to 70 hour weeks in order to sustain a small private practice. We will see if this is just a mirage, but in the meantime, I will also be providing commentary on articles in that magazine.

This will be another short one because it comes from a short article.

“We recommend building a program to mentor your existing staff to become those next clinic directors”

I can’t ever remember a job in which mentoring actually took place formally. I have worked for Wal-Mart, and although it was a great learning experience, the learning wasn’t formal. I learned more by watching the culture from the top down. When looking at the top, there was the GM. I can remember my interview with the GM as a 15 year-old. He asked me about school and I was very cocky back then. I told him that I wasn’t worried about school. He made the comment, “that either means you’re really smart…or really stupid.” Looking back, that was a memorable moment. As a kid, I just blew it off, but as an adult I hope that my kids never make such a shortsighted comment.

I learned a lot while at Sam’s club and made friends that are still friends to this day (20 years later). I made huge mistakes and should’ve been fired for some of them, but I wasn’t and I learned from them. I kept learning through the years and quit the same year that I earned employee of the year. That’s the same year that I got accepted into PT school.

From there I went to World’s Gym Joliet. Again, I learned a lot, but not formally. The owner did not have a way of promoting talent. When a person has no direction and no way to succeed, then the person will slowly sink back to mediocrity. At this job, I became a great student of PT, as it gave me plenty of time to study, but I was a horrible employee. I only did what was needed to get the job done because I didn’t know what else to do aside from the list at the desk. This was horrible management because we didn’t have a way to excel. Needless to say, the gym is closed.

In none of my PT jobs do I have a way to become management. I have specifically asked this of my jobs (all of them to be exact) and the answers are almost all the same, “we don’t know how to promote someone to management” or “we don’t have any room for additional management”. This doesn’t make sense. A manager is someone that takes on more responsibility than those they serve. Although it typically comes with additional resources, it doesn’t always. I don’t think that those above me see the loss that takes place when I am pigeonholed into a lesser role.

I can’t give a good reason why a clinic director would not take the time to develop those they serve to take their place. I can think of many reasons, but none of them good.

Fear: If I groom someone to take my place, then what stops him or her from taking my place? I groom many students to do what I do in the clinic. None of them will be as good as I am with the information that they received from me. This is not an arrogant statement, but I spent thousands of hours studying the information and understanding the information in the studies. The students simply get PowerPoint presentations of my knowledge. This is much better than what they get in school regarding specific topics, but at no point will they obtain my understanding through PowerPoint alone. The same can be said for a clinic director grooming an understudy to be a director. I can obtain the same information, but I shouldn’t know as much as the director regarding the information…unless the director didn’t spend the same amount of study to learn the information.

Power: If only one person can do the job, then all else must bow down to that person as an authority figure. There are certain things that only the director can accomplish, because only the director knows how to accomplish certain things. It can never be delegated because then the director will have slightly less power than prior to delegation.

Lack of talent: This is not a good reason to not develop a person. This is the poor management to begin with, as if a “person wouldn’t be rehired, then the person should e fired”. I don’t know who said it, but I heard it from Entre Leadership podcast.

“Develop a career ladder in your business that points to a staff therapist growing to become a manager”

This seems logical. Those that want to succeed will then have a structured way to climb the ladder to the top. Not everyone wants to be at the top. Not everyone wants the responsibility or the time constraints that come with moving up the ladder. Those that do though…should have a written way to climb the ladder so that one’s wheels aren’t spinning.

This is a quick statement of sales. In healthcare, we are preprogrammed by administration, or bosses, to take your money. It doesn’t always sound this sinister, but it may sound like one of the following:

Make sure that we don’t have a waitlist. We don’t want people to have to wait to get in for an appointment. This sounds very altruistic, but what we could hear if we fine tune our frequency is: don’t let this patient get better over time or make sure that this patient doesn’t hang up and go somewhere else.

If you have something else to work on, make sure that the patient is completely satisfied with their stay. This could also mean that you haven’t treated the patient for enough visits to make as much money from the patient as the doctor has enabled us to make. For instance, if the prescription says 3x/week for 4 weeks, but you are better after 3-5 visits, then any visit not seen up to 12 is considered loss of potential revenue.

There is nothing wrong with making patients feel good in order to get them to do what we want them to do. I hear: modalities are easy to apply and we can get paid to do them so…why not?

“A good salesperson works hard to ensure the answers are all just different shades of ‘yes’”

If you want something, don’t take no for an answer. As much as I agree with this, I also have to disagree with this. You have to be willing to establish how important it is to “sell” your wares. For instance, regarding physical therapy that “ware” that we are selling is the new evaluation. It pays the most and leads to many additional visits. We have to ask ourselves if we are willing to sacrifice and what are we willing to sacrifice in order to get that new evaluation? Are we willing to sacrifice a lunch break? Are we willing to pay our employees overtime (most companies have gotten around this by going salary)? Is the employee willing to stay late? Are we wiling to sacrifice patient care by double booking a patient? We have to establish our priorities, so sometimes it is okay to say no if it doesn’t “make the boat go faster”. Again, Google this phrase…it’s that important.

A lifetime of exercise when compared to an IRA versus starting late comparing to lost interest.
You know…I spent a heck of a lot of time studying the spine. Over the years, reading at least 1 hour per week since 2007, I would anticipate that I read over 900 journal articles since entering the profession. Since more than 80% of those are on orthopedic issues, I would say that I have a put a lot of deposits into my bank of ortho care. At this point, I am just reading spine stuff for fun.
I liken this to putting in deposits, over the course of time, into a retirement fund. After much time, you can see how the little deposits over time add up to millions of dollars. That’s how I feel about spine stuff.
Now, I am trying my darnedest to learn vestibular stuff. It is taking an inordinate amount of time in order to learn the basics. I am so far behind those that are experts in the field that I feel like a baby on the subject. I liken this to the person that hasn’t saved for retirement. I have to frantically read and learn as much information in as short a time period as possible in order to be even minimally competent to treat these disorders. I am learning, but the process is slow.
There is an argument regarding training your weaknesses in order to get better or making your strengths stronger.
I have to spend a lot of time to get a little better at treating one disorder, when I was so used to spending a little time to make huge jumps treating others.
The struggle is real. It’s hard to find that master of all trades. Usually you’ll just find the jack of none.

MORAL OF THE STORY: Stop your whining over your herniated disc, bulging disc or exploding disc. You are probably not the outlier. If your pain is lasting longer than six months, your disc is probably healed, but you still move like crap. Start to move better and take better care of yourself and the improvements will follow. In general, this means that you are most likely the problem…not your back.

Also, I will be taking a couple of weeks off from reading and writing to travel with the family. Taking some time to breathe. If you enjoy the blog, please add a topic that you would like to see covered at a later date.

“Lumbar disc hernia (LDH) is a common cause of low back pain and radicular leg pain…majority of LDH patients recover spontaneously…Purpose of the present study was to investigate the natural history of the morphologic changes of LDH on MRI and to assess correlations with the type of LDH and the clinical outcome”

First, disc herniations are a common cause of pain. I believe this to be true and the research consistently reports this fact. The part that doesn’t get reported is the second part of the statement being that spontaneous recovery is normal.

When people come into the clinic, they have this seemingly rehearsed story of how they had an MRI and was told that they have a bulging/herniated/exploding (maybe a little overboard) disc. The doctors never tell them that this can recover on its own and patients then wear the herniated disc patch for the rest of their lives.

As you will see, you no longer need to wear that patch if your were told that you have an exploding disc.

“…42 patients…mean age of 42…unilateral leg pain and low back pain…symptomatic level was L2-3 in 8 cases, L3-4 in 6 cases, L4-5 in 15 cases and L5-S1 in 13 cases”

Let’s start here.

The lumbar spine is labeled as L1-5 and the sacral spine then starts. The intersection between the lumbar spine and the sacrum is L5-S1. The segments are named by the upper segment first-lower segment second.

Some interesting notes regarding this study:

66% of the patients have symptoms coming from the lower lumbar segments, those being L4-S1. This is inconsistent with published research reporting that up to 95% of symptoms come from these lower segments.

Therefore, 34% of symptoms are coming from the upper segments. Again, previous research notes that only 5% of symptoms come from these segments.

Unilateral leg pain simply means that only one leg is affected. For those that may have experienced sciatica in the past, you will remember that it was only one leg that experienced symptoms. If you have symptoms in both legs, then it may not be sciatica.

“All patients underwent MRI examinations every three months for a period of 3-24 months”

This is not affordable for most and won’t be approved by any insurance that I have encountered. The reason for the frequent MRI’s is to see how things change over time.

“LDH was classified into three types: protrusion (n=7), extrusion (n=17 and sequestration (n=18)”

Here comes the jelly donut theory. If you have heard it, then you can pass this paragraph up. Think of the disc as a jelly donut (I know that this is an oversimplification, but this model makes the most sense…even if it is not the most accurate).

A protrusion means that the outer portion of the donut (the actual donut itself) has been deformed. If you plug the hole of the jelly donut so that the jelly can’t come out of the hole, you will be able to follow along with the rest of the idea. I personally don’t like jelly donuts. I much prefer custard or cream. Speaking of that, Tim Hortons has the best filled donuts that I have ever had. This reminds me of a trip to Canada with my best buddy Carl. If I have the time later, some stories from this road trip may come out. Back to business; if you squeeze the donut on an edge lightly, you will start to squeeze the jelly away from the area that you are squeezing. If you squeeze a little harder, you will see the donut “bulge” just prior to the jelly coming out. This is a protrusion.

An extrusion means that the jelly has escaped! Oh no! Now what? No big deal. You will see later that this may actually be a better situation for you than the protrusion.

A sequestration means that not only has the jelly escaped, but a piece has broken off and hit the floor. If enough nuclear material (the jelly inside the disc) breaks through the annulus (the donut in the example), then it may break off and be free floating in the spinal canal (near the nerves of the spine). This again may not be as bad as it sounds.

Correlation between the clinical outcome and spontaneous changes of the herniated mass on MRI (6 months)

MRI change

Excellent

Good

Poor

Total%

Disappearance

6

2

0

19

More than 50% reduction

11

18

0

69

Little or no reduction

0

1

4

12

Total

40

50

10

100

What this means is that in 19% of patients, the herniation seen on the MRI disappeared over the course of time. Better yet, about 88% improved significantly over the course of time. You are not your MRI… at least not for long.

6.

Type of herniation

Case

Duration of symptoms

Protrusion

3 cases in total

3-14 weeks with 8 weeks average

Extrusion

17 cases

4-8 weeks with 4.8 weeks average

Sequestration

18 cases

1-5 weeks with 3.2 weeks average

What does this chart mean? Those that have a “more serious” appearing herniation on MRI actually respond faster than those with a smaller herniation. You are not your MRI…at least not for long

This is a great article for the “n” of one crowd. Not every article has to be a randomized control trial and sometimes we can learn much more from a case report than from a systematic review. This is one case report that taught me to be a little more exhaustive than I typically am when treating a patient. When a patient presents to the clinic with facial pain, the “jump to conclusion” idea is that the patient has larger issues that need to be addressed, as this is a sign of a cranial nerve (think direct to the brain nerve) dysfunction. I forgot some details of the nervous system, or a better way of saying it is that I didn’t have a complete understanding of this coming out of PT school that this review is more of a clinical application of the anatomy in order for it to make more sense. My ego is not too big to say that I am still learning daily. This article makes me a better therapist tomorrow than I was yesterday. Thank you J. Lincoln.

Big picture, the patient improved. We can’t draw cause and effect conclusions from a single case, but we can take the information provided and use it on a later patient in which stronger research-based interventions have failed the patient.

“female…with symptoms of unilateral right sided head,face,ear, neck, shoulder and arm pain, as well as subjective sensation of swelling in the right side of the face and anterior triangle of the neck”

Yeah…we don’t particularly like seeing these types of patients. Especially not on a Friday after noon at 4PM. These symptoms are going to be difficult to try to figure out. Many therapists (myself included when I was a young buck) would just write this patient off as one of two things:

psychosomatic: look it up. You will find that the psycho plays a role in the pain presentation. By psycho, I don’t always mean the patient, but the patient’s perception of the pain.

secondary gain: This patient was either in a car accident looking for litigation, is trying to score some time off of work, or is trying to get money without working for it.

Needless to say, I don’t tend to lump patients into these categories as quickly as I did in the past ( I still do, as this is also a part of classifying patients), but I will at least take a crack at helping the patient before jumping to one of the above conclusions. On a side note: if you are faking/exaggerating or seeking some sort of financial gain, please don’t seek me out. I take pride in thoroughly assessing you and if I find inconsistencies in your presentation, it will not look good for your case.

“referred for neck pain…complained of a constant ache in the right shoulder and neck extending down the entire anterior aspect of the right arm…intermittent pain in the right side of the face, ear and head as well as a constant sensation of swelling in the right side of the face and anterior triangle of the neck…waking at night with right arm pain…intermittent pins and needles in the right fingertips…aggravating activites included reaching or lifting with the right arm, ironing or wringing out clothes. Cold weather or having influenza generally made all symptoms worse…blowing her nose or sneezing specifically increased her facial pain.”

Get ready to swim because we are going into the deep end.

Neck pain radiating down the arm. This is a very common symptom and can be coming from any structure that radiates symptoms down the arm (such as disc, nerve, facet) or from the brain’s heightened state of response to threat. This is a common symptom and I always think that there is a mechanical problem and force the patient’s symptoms to make me change my mind.

When assessing all patients, it is like one big chess game. Every movement and question that I ask of you provides me with your first move. I always let the patient start, except for very rare cases. Once the patient starts with their history or the first movements, the chess game begins. Every move the patient makes leads me to my next move. It is really like one complex dance. I will follow your lead and then take the lead when your body has given me my checkmate. Once I know how to win, I completely take the lead.

intermittent pain in the face, ear and head leads most therapists to start thinking cranial nerves. These nerves are interesting because they don’t go through the spine. Think of it this way, why should the nerves go down into the spine only to come back up into the face. There is a much shorter distance from the brain to the face. When the face starts experiencing symptoms, we think brain first (and always keep this in the back of our minds if there is no change in the patient’s symptoms with movement, as nerves from the brain to the face won’t change much with neck movements). Secondly, the upper portion of the neck can refer into the head and face. Neck movement’s can affect these symptoms. This is why it is important to have a thorough evaluation.

waking up at night with arm pain can be considered a red flag (think red light as our stop sign) and the therapist may start thinking of things such as cancer, but again the mechanical evaluation will help to start weeding out the white board (House MD reference).

cold weather or influenza: This could also signal a systemic issue having a role in the patient’s systems.

Overall, the white board just got very confusing.

“insidious onset of pain over a 12 month period, which had gradually worsened…no past history of shoulder or cervical spine injury…medical history included …diabetes, angina (chest pain), dizziness associated with postural changes and blurred vision bilaterally (both eyes)”

Big picture, this patient has a lot of stuff going on! I would call the doctor to ensure that he/she is aware of the atypical symptoms of blurred vision (possibly brain issue), dizziness (could be brain issue, neck issue, eye issue or ear issue) and chest pain (could be neck issue or heart issue). The fact that the patient is worsening over time is also a red flag that would also need to be alerted to the physician.

Many would think that the physician should already know all of this, but as a former teacher “Master John Luby” once said: “Never should on yourself” (say it fast and it will make sense). Most all of us have been to the doctor. I hear stories frequently from patients that they only see the physician for 5-10 minutes (if they ever see the physician at all). The therapist gets anywhere from 30 minutes to 1 hour with the patient and more information can be garnered in this time period (if the therapist cares enough to ask).

“protracted cervical spine with forward head”

This is unfortunately more and more common. I can count on one finger how many patients enter the clinic with good posture. If your posture is crappy, then your movement will also be crappy. If you can’t stand still with good form, what makes you think that you can walk, run, jump, squat, or lift with good form.

“an increase in the shoulder and neck pain at the end of range for left rotation and left lateral flexion”

This would indicate that opening up the facet joints would provoke symptoms. The spine has 3 holes in it…don’t worry, they are supposed to be there. When you move in a direction you can only do 1 of 2 thing to the hole: open or close. When you move to the left (either side bend like holding a phone to your ear or rotating in such a way to look over the left shoulder) you close down the left holes of the neck and open up the right holes of the neck. Opening up the right hole provokes symptoms.

“Cervical spine extension produced central thoracic pain. Flexion, right rotation and right lateral flexion were asymptomatic”

looking up was no good, but looking right and leaning right were great. Looking down was okay. This creates a complicating factor because when you look down, you open the right hole and when you look up, you close the right hole. This patient will not be as simple as which holes are opening and closing.

“arm,shoulder and neck pain was increased with flexion from 90 degrees through end range, abduction initially at 100 degrees through end range, and at the end of range with the hand behind the back movement”

White board: shoulder problem, neck problem, nerve problem.

Raising the arm can place tension on a nerve (they don’t like tension). Placing the arm behind the back doesn’t place tension on the same nerve, so this would start to rule out nerve tension as the major source of problems.

Neck problems can mimick all of the above symptoms, so not ruled out yet.

Shoulder problems can mimic the shoulder pain with the movement, but doesn’t typically cause neck pain with the movements.

Based on the pain presentation, we should probably start by looking at the neck.

“Position assessment of the axis vertebra via palpation revealed the right transverse process to be prominent posteriorly as well as tender. This possibly suggested some rotation of this vertebra”

I understand what the author is saying, but I am so far removed from assessing each individual segment that I find it hard to believe that this is still a major component of performing a cervical evaluation.

“patient was given a modified…neural mobilization exercise for home”

This doesn’t make sense to me when the author initially thought that there was a neck problem based on palpation. If I thought that you had a lug nut loose, I wouldn’t recommend putting air in the tire as a fix.

“reported an initial increase in symptoms for 2 days and then large decrease for subsequent 4 days…active cervical spine movements reproduced right shoulder and neck pain at the end range or right rotation and right lateral flexion…it was decided to test for upper cervical spine stability…symptoms had virtually disappeared to a minor sensation…directly after treatment (headache snag).

Again, there are some topics here that seem like illogical jumps. The symptoms in the neck shifted sided from left to right. This is common, so I can understand that the symptoms shifted sides, but I can’t understand how the therapist made the jump to test for cervical instability after already having done all of the cervical movements. When a spine is unstable, it is like balancing a golf ball on a golf tee. If everything is aligned, the golf ball will stay on the tee, but if there is a slight change in alignment, off the tee it falls. Guess what your head resembles?! If there is a suspicion of cervical instability, this is a major clinical sign that needs to be assessed.

“Infections in the tonsils, middle ear, teeth and nose may drain into the cervical spine region and the subsequent inflammation may lead to loosening of the transverse ligament attachments”

First, I didn’t know this. Second, this is a guess at best to state that this is the reason for the “loosening” of the ligaments of the spine.

“It is therefore possible that this patient’s increased mobility was due to chronic loosening of the transverse ligament over time.”

This is a stretch and I would say long shot. First, we don’t know how mobile or hypermobile this patient was prior to the incident. The “increased mobility” may be the patient’s norm. We all know some people that can touch the floor and others that can’t even touch their knees. This may be the person’s norm.

Also, if the infections are causing the ligament loosening, then the exercises will not have a long-term effect on someone that continues to experience infections. If this is the case, then the best way to treat the facial symptoms is to treat the infection and wait to see if the ligament tightens up and the symptoms disappear.

“This patient presented with pain at rest, suggesting the spine’s inability to maintain a sufficient neutral zone to prevent abnormal stresses on upper cervical spine…the development of a clinical instability situation”

If something has increased mobility from what is expected as normal, it doesn’t make sense to mobilize the segment. I don’t understand the author’s rationale for mobilizing a hypermobile segment. This may just be my ignorance though.

The patient improved over a short number of sessions. This is obviously the goal of therapy. If this patient’s symptoms were unchanged or worsened over the course of 6 visits, then it would be appropriate to communicate with a physician that either referred the patient or that the patient would like to see. This is why it is important to shop around for therapists. We have to demonstrate functional improvement. Sometimes that function may just be reducing and eliminating pain so that you can continue to watch Game of Thrones or play the latest game on FB.

Do you want to have back surgery? A therapist highly trained in treating back pain can tell you the odds that you will end up on a surgical table. This is a great study for patients that are debating surgical intervention. If you are already scheduled for surgery, ask your physician for a second opinion from a specially trained PT. What do you have to lose? Not all PT’s are trained the same and if your PT didn’t do a thorough assessment, go see a PT certified or Diplomaed in Mechanical Diagnosis and Therapy. I would be able to give you an honest assessment of whether therapy will be able to help you. Seek out someone trained in MDT.

MORAL OF THE STORY:

With patients that present to the clinic sub-acutely, with complaints of lower extremity pain referred from the spine, a MDT evaluation in order to assess for CP would be beneficial to predict non-response to conservative care. Patients that do not demonstrate the CP are greater than six times more likely to require surgery than patients that demonstrate CP.

A Critical Appraisal of Centralization and its Ability to Predict Surgical Outcome

P: For patients with back and leg pain

I: can patients that do not demonstrate the centralization phenomenon (CP)

C: as compared to patients that demonstrate the CP

O: be utilized to predict a surgical outcome

Reviewer:

Vincent Gutierrez, PT, MPT, cert. MDT

Search:

Ovidsp with keyword terms “centralization and prognosis”. The results were limited to full text. 58 citations were found with no limit to year published.

The purpose of this study is to evaluate the CP prognostic value in determining conservative or surgical treatment. This is a prospective cohort study of patients with unremitting back and leg pain, between 18 and 60 years of age. One hundred fourteen consecutive patients meeting these criteria were initially entered in the study and 54 patients were excluded based on the exclusion criteria. The exclusion criteria consisted of the following: previous lumbar spinal operation, pregnancy, serious spinal pathology, other serious pathology, Danish not the patient’s first language, symptoms present greater than 14 weeks and lack of consent.

Baseline data including the Nottingham Health Profile (NHP), Low Back Pain Rating Scale (LBPRS), demographic data and the Quebec Task Force (QTF) category of symptom referral. The examining therapist was blinded to the baseline data and performed a Mechanical Diagnosis and Therapy (MDT) evaluation in order to classify the subject as “centralizer” (CG), indicating that the most distal symptom was abolished and remained abolished upon returning to a neutral position, or “noncentralizer” (NCG), indicating no change during the MDT evaluation or the symptoms changed to a more distal location. Twenty-five patients were allocated to the CG and 35 patients to the NCG.

The treatment was the same for both the CG and NCG, consisting of “watchful waiting”. This included bed rest for those with neurological deficit and “light mobilization” for those without neurological deficit. Follow-up data was obtained at 1,2,3,6, and 12 months. Three patients from the CG and 16 from the NCG underwent surgery by the one-year follow-up. All patients were accounted for in the results.

Appraisal:

The authors satisfied six of the nine questions regarding the Quality Appraisal Checklist. A follow-up study, to establish the reliability of the results was not performed, and patients entered the study with varying acuity of symptoms. The examiner was blinded from the data collection, and the treating therapists were blinded from the examiner’s assessment.

Assessing the CP can predict conservative compared to surgical treatment requirements with 84% specificity and 54% specificity. The odds ratio (OR) for surgery in the NCG was calculated to be 6.17, with a 95% confidence interval (CI).

There are increasing numbers of total knee replacements performed yearly. Medicare is initiating a bundled payment initiative for all facilities in 2017 and many are participating for the previous 2 years. What does this mean for the patients? Theoretically, it means more efficient care, with better outcomes, because patients will be more closely monitored. For instance, the hospital, and those employed by the hospital, stands to profit moreso than normal when patients have great success rates with more efficient care (see fewer visits performed). From my perspective it is about 2 things: 1. Improve patient’s outcomes 2. Do this with less expense. Our country spends a large percentage of our money on healthcare, but when looked at from a broad perspective, we do a poor job of keeping our people healthy. Whatever the reason, this needs to change.

Those of us in healthcare understand that the insurance company drives the type of treatment that a patient can receive. Most patients, in my experience, will not pay out of pocket for care that they feel entitled to and will stop care when the entitlement is exhausted. We, as healthcare professionals, have to do a better job of demonstrating value to patients. I spend, like many people, over $1,500/year in order to have a cell phone with internet access. This amount of money would pay for 1 visit of PT per week for almost 6 months, if the patient paid out of pocket. BLASPHEMY! Why should I pay for something that the insurance company will cover?

The insurance companies are becoming more aware of our downfalls as a profession. One major downfall is one of the deadly sins…GREED! When patient’s have to take more responsibility for their own health care and have to share more of the costs of health care, then the patient will become more aware of how his/her dollars are being spent…or go broke in the process. Gratefully, I work for a company that doesn’t push profit as much as it pushes “right patient, right time, right treatment”. Patients need to see that not all therapy is the same and sometimes…just sometimes…the patient can have both high quality therapy at a low cost.

Bringing us to today’s post. Come and knock on our door…we’ve been waiting for your…and the kisses are hers and hers and his…three’s company too. When I think of single leg stance, I think of the flamingo stance. When I think of the flamingo stance, I think of terri/torrie/cindy (blond from the show) standing on one leg while at the zoo. Moral of the story is: patients with better balance do better overall. Patients can achieve better balance by working on the skill over time. Depending on the source, the NIH reports that it takes upwards of 50 hours of practice to improve balance. Go practice now.

Can you stand on one foot?

Can you do this with eyes closed?

Can you do this equally on both sides?

Can you do the eyes closed version for at least half as long as the eyes opened version?

If not, go see a PT. You can look at the APTA website or your state’s local website (Illinois Physical Therapy Association) in order to find a provider.

Intro: 37% of TKA’s still have functional limitations p one year. Diminished walking speed, difficulty ascending/descending stairs, inability to return to sport are chief functional complaints. During TKA surgery several tendons, capsule, and remaining ligaments are retightened to restore the joint spaces deteriorated by the arthritis. Some of the knee ligaments are removed or released, which may affect mechanoreceptors/balance.

PURPOSE:

To determine the feasibility of applying a balance exercise program in patients with TKA

To investigate whether an F (functional) T (training) program supplemented with a balance exercise program (FT+B) could improve function compared to FT program alone

To test the method and calculate a sample size for a future RCT with a larger sample size

METHOD: Double-blind pilot RCT (very strong evidence)

Inclusion: TKA in the previous 2-6 months (meaning not eligible for study if the TKA was before 2 months previous)

Adherence for both groups is 100% and the HEP adherence was similar (filled out logs)

walking speed continued to improve over the course of 6 months for the FT+B group and was 25% better than the FT only group.

The interesting fact is that improvement continued up to 6 months, when previous literature describes 3 months and done.

Single leg stance: FT+B improved (as expected due to SAID), but the FT group either maintained or worsened on speed and balance.

DISCUSSION: FT+B demonstrates clinically important differences in walking speed, SLS, stiffness and pain, without adverse events. Subjects in the FT+B could balance on average 4 seconds longer than baseline. This may be important for weight bearing during the stance phase of walking. Performance-based measures should be used in place of subjective measures.

TAKE HOME: Patients will benefit from the addition of balance exercises post-surgically. It may be prudent to discuss with the surgeons of increasing the length of stay in therapy and decreasing the number of visits per week, as progress continues to occur past the 3 months initially surmised. Each patient should be tested with one or more of the following:

SLS

Chair rise test

Gait speed: important indicator of function/independence/death

Balance test (excluding Tinetti due to possible ceiling affect when the patient no longer needs an AD).